Inspection on 09/02/09 for Feltwell Lodge

This inspection was carried out on 9th February 2009.

CSCI found this care home to be providing an Good service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Feltwell Lodge 06/03/07

Feltwell Lodge 16/02/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Feltwell Lodge Lodge Road Feltwell Thetford Norfolk IP26 4DR     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Andy Green     Date: 0 9 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 23 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 23 Information about the care home Name of care home: Address: Feltwell Lodge Lodge Road Feltwell Thetford Norfolk IP26 4DR 01366728282 01366727361 feltwelllodge@aol.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mrs Sandra Elizabeth Hanley,Mr Thomas Paul Hanley care home 23 Number of places (if applicable): Under 65 Over 65 8 15 dementia old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home 0 0 Feltwell Lodge is a care home providing personal care and accommodation to twentythree Older people, eight of whom may have dementia. The Victorian house is set in five acres of landscaped gardens, surrounded by woodlands and provides a peaceful location in which to live. The home is situated on the edge of Thetford forest and is two miles from the village of Feltwell. It consists of a two-storey building, with accommodation on the ground and first floor. There are four shared rooms, fifteen single, seven with en-suite. There is a passenger lift and stairway for access to the first floor. Care Homes for Older People Page 4 of 23 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We, the Commision for Social Inspection, undertook an unannounced inspection on 9th February 2009. The home completed an AQAA (Annual Quality Assurance Assessment) which is a self audit tool to give the home an opportunity evaluate how they are meeting standards and regulations. We spoke with the manager, care staff and residents to gather their views regarding the services offered in the home. A number of records were inspected including care plans, training records, staff files, medication records and fire testing records. A tour of the building and grounds was also undertaken. Care Homes for Older People Page 5 of 23 Care Homes for Older People Page 6 of 23 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 7 of 23 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 8 of 23 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home carries out thorough assessments out to ensure that prospective residents needs can be met. Evidence: The registered manager and the care manager carry out thorough assessments of prospective residents to ensure that personal care and support needs can be met. Visits are arranged where possible to the home including relatives where possible. The manager stated that a number of admissions to the home are generated through a person having an initial respite stay in the home which gives an easier transition as the placement becomes permanent Care Homes for Older People Page 9 of 23 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents health and personal care needs are set out in individual care plans and there are effective systems in place to show that these are met. Evidence: Four care plans were inspected and they contained a range of detailed information regarding the care and support needs of each individual. The care plans were up to date and included a photograph and relevant contact details in case of emergency. Information regarding care and support included medical history, daily routines, personal hygiene,nutritional audits, dietary preferences, risk assessments, moving and handling audits, activities, property list and funeral arrangements. Visits from health care professionals eg GPs, district nurses and community psychiatric nurses are recorded separately. The home continues to consult with the Falls Awareness Team to minimise the risk to residents of falls. Care plans and any changing needs are reviewed and monitored on a monthly basis, involving the residents and their relatives where possible. Evidence of detailed recent reviews were Care Homes for Older People Page 10 of 23 Evidence: seen. Residents spoken to, together with the comment cards received by the Commission, confirmed that health care needs are being met. All residents spoken to, and evidence through observation, confirmed that residents are treated with respect and their dignity and privacy is maintained at all times. Observations made during the inspection evidenced that care staff were friendly, responsive and professional in their attitude towards residents. The medication round was observed and was being administered by an experienced member of staff. The Care Manager continues to have the responsibility for the ordering of medication. All staff administering medication have received appropriate training. There is a Controlled Drugs cabinet and the records for this and the medication administration records sheets were completed satisfactorily. The home has recently received a satisfactory pharmacy inspection January 2009. Care Homes for Older People Page 11 of 23 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are social and creative activities and a choice of meals that reflect the preferences of the residents. Evidence: The home has a programme of activities and a member of staff is the the designated Activities Organiser. There continues to be daily activities every afternoon, as well as music and games on two mornings which are planned on a weekly basis. A programme of activities is displayed which includes musical entertainment, bingo, light exercises, board games and craft sessions. The home arranges an annual clothes show and a number of Christmas events. A hairdresser visits regularly and there are also manicure sessions. Newspapers and television are available to residents. There was a lively musical entertainment session taking place on the morning of the inspection which was being enjoyed by a group of residents. Residents spoken with confirmed that they enjoyed participating in activities but that they could also spend time in their rooms if they so wished. It was encouraging to meet a resident who was Care Homes for Older People Page 12 of 23 Evidence: very pleased to have been able to have her own cat in her room and the staff continue to support her in caring for it. The home continues to encourage contact with family and friends. Care plans also showed evidence of relatives involvement in care plans and reviews. The cook has a Food Hygiene qualification and responds positively to suggestions and feedback from the residents. The menu provides two choices and the cook continues to meet each new resident regarding their food preferences. Residents spoken with said that the food was of good quality.The lunch was observed to be well presented and nutritious with choices being offered. A dietary audit is in place entitled Malnutrition Universal Screening Tool (MUST) which is used for all residents and care staff are trained in its use. Care Homes for Older People Page 13 of 23 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a clear complaints procedure to make sure that service users have their complaints or concerns listened to and acted upon properly. Evidence: The home has a clear complaints procedure including agreed timescales to ensure that all complaints are investigated and actioned appropriately. The home has not received any complaints since the last inspection. CSCI has also not received any complaints regarding the home. Relatives are made aware of the complaints procedure to ensure that any concerns can be raised and dealt with appropriately by the manager. The home has a satisfactory policy regarding Adult Protection, which is in line with Local Authority policies. Staff continue to receive updates regarding training in the protection of vulnerable adults so that service users are protected from abuse. It was noted during the inspection that care staff spoke to service users in a friendly, social and respectful manner. Care Homes for Older People Page 14 of 23 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a clean, homely and comfortable environment, which meets residents needs but hot water regulators need to be installed to wash hand basins. Evidence: The premises continue to be suitable for the residents needs and are accessible, safe and there is a ongoing programme of maintenance. The home is comfortable, bright, airy and clean. The furnishings and fittings are of good quality. There is an attractive conservatory area on entering the home, which provides a quiet area for residents. A number of bedrooms were seen and they were comfortable and well maintained. Residents are encouraged to personalise their bedrooms with photographs, pictures, television and items of furniture if they so wish. There is a large lounge and dining room overlooking the garden. Residents have access to the homes extensive gardens and grounds with a number of seated areas From the decorating and maintenance records a variety of redecoration have been undertaken since the last inspection. Redecoration and new carpets and furniture have been carried out in a number of bedrooms and lounge areas. A new fridge and freezer have also been purchased since the last inspection. Regulators on basin taps are in the process of being fitted, but there is a continuing Care Homes for Older People Page 15 of 23 Evidence: requirement for work to be carried out on all wash hand basins to ensure that there is a safe water temperature. Care Homes for Older People Page 16 of 23 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes recruitment processes ensure that residents are protected from harm. Care staff receive appropriate training to ensure that they are competent to deliver care to residents. Evidence: Three members of staff personnel files were seen and they contained appropriate information including their application form, two references and evidence of a satisfactory Criminal Records Bureau checks. The homes training continues to be effectively organised and updates in mandatory and client specific courses. NVQ training is well established in the home and the majority of care staff have completed NVQ at either level 2 or 3. Evidence of individual training was seen including dates for refreshers and updates to ensure continuing safe practice. Examples of training in the last twelve months included safeguarding adults, dementia care, moving and handling, first aid, fire safety and infection control. Three members of care staff were interviewed and they confirmed that they had received a thorough induction and ongoing training throughout the year. Care Homes for Older People Page 17 of 23 Care Homes for Older People Page 18 of 23 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed and the manager provides supportive leadership and guidance to staff to ensure that service users receive a good and safe standard of care. Evidence: The registered manager continues to provide a clear and supportive style of management in collaboration with the care manager. Staff members spoken with confirmed that they felt well supported by the management team in the home. Recorded supervision sessions are in place for all a staff to ensure that their practice and development needs are regularly monitored. Staff interviewed confirmed that they received supervision every 6-8 weeks. Regular staff meetings continue to be held with agendas and minutes provided so that staff can freely raise care issues and items of business. Care Homes for Older People Page 19 of 23 Evidence: Health and safety checks are in place. Fire testing records were inspected and they were accurate. Care Homes for Older People Page 20 of 23 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 25 13(4) The registered person must 01/07/2007 ensure that regulators continue to be fitted to hot taps to maintain the water at a safe temperature. Care Homes for Older People Page 21 of 23 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 25 13 The home must provide regulators to all hand basins to maintain the hot water at a safe temperature To ensure that residents are protected from potential harm. 26/04/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Older People Page 22 of 23 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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